COVID-19 vaccination in patients at higher risk of anaphylaxis: A safe and pragmatic approach

• We set up a COVID-19 vaccine clinic in NHS Lothian due to concerns of anaphylaxis. • The clinic was run by a general physician as we did not carry out skin testing. • We gave 207 vaccines; 41 reactions occurred, none severe, and with no anaphylaxis. • This evidence contributes to the safety of COVID-19 vaccines. • Triage and monitoring enables vaccination for many who might otherwise be excluded. At the start of the COVID-19 vaccine rollout, there was significant concern about anaphylaxis. We therefore set up a triage service and monitored vaccine clinic in NHS Lothian, UK. Despite MHRA guidance, we did not perform skin testing, as its reliability was uncertain and posed practical challenges that may have delayed vaccination. Over 700 patients were triaged by an allergy specialist, who accepted referrals with concern of allergy to vaccine excipients, or a previous serious reaction to a COVID-19 vaccine. Vaccine type was advised at triage, and on 58 occasions pre-treatment with oral antihistamine was advised. In total, 207 vaccinations were given in a monitored vaccine clinic run by a general physician, to 186 individuals. Fourty-one reactions occurred, with the greatest proportion in those with a previous reaction to a COVID-19 vaccine. All were observed within 30 min and were predominantly orofacial swelling and tingling, and skin reactions. All were managed with antihistamines, paracetamol, or personal rescue medications. No anaphylaxis occurred, and IM adrenaline was never given. Out of 186 patients, 169 were advised they could have future vaccinations in a community setting. We propose that the format of this clinic could be extended to support all vaccination programmes.